New Politics, an Opportunity for Maternal Health Advancement in Eastern Myanmar: An Integrative Review

ABSTRACT Myanmar (formerly Burma) is a southeast Asian country, with a long history of military dictatorship, human rights violations, and poor health indicators. The health situation is particularly dire among pregnant women in the ethnic minorities of the eastern provinces (Kachin, Shan, Mon, Karen and Karenni regions). This integrative review investigates the current status of maternal mortality in eastern Myanmar in the context of armed conflict between various separatist groups and the military regime. The review examines the underlying factors contributing to high maternal mortality in eastern Myanmar and assesses gaps in the existing research, suggesting areas for further research and policy response. Uncovered were a number of underlying factors uniquely contributing to maternal mortality in eastern Myanmar. These could be grouped into the following analytical themes: ongoing conflict, health system deficits, and political and socioeconomic influences. Abortion was interestingly not identified as an important contributor to maternal mortality. Recent political liberalization may provide space to act upon identified roles and opportunities for the Myanmar Government, the international community, and non-governmental organizations (NGOs) in a manner that positively impacts on maternal healthcare in the eastern regions of Myanmar. This review makes a number of recommendations to this effect.


INTRODUCTION
Myanmar (formerly Burma) is a populous and impoverished southeast Asian country, with a long history of military rule and political conflicts characterized by widespread human rights violations. Myanmar's population of pregnant women are particularly at risk, and that risk is significantly higher among pregnant women of ethnic minority groups in the eastern provinces. Very limited data for the strife-ridden eastern provinces have made it difficult to establish a pattern of the prevalence of maternal mortality in Myanmar. Officially, the country's Central Statistical Organization reported the nation's urban maternal mortality ratio (MMR) to be 123 per 100,000 livebirths and the rural MMR to be 157 (1). International bodies, such as the WHO, UNICEF, UNFPA, and World Bank, however, suggest that the overall MMR may be as high while nominally free, the reality is that many health services require a user fee (9) that the Government has imposed as a so-called community cost-sharing scheme (10). Family planning services, such as contraception, are difficult to obtain, particularly in the eastern regions (8). As recently as 2000, family planning services were virtually unavailable in Myanmar. According to the Ministry of Health, the national unmet need for family planning is 17.7% (11), a rate similar to that found by the UN (12). However, the unmet need in the eastern regions has been documented at greater than 60% (13).
Many women in Myanmar resort to illegal abortions as the primary means of contraception (14). Officially, Myanmar makes antenatal care available to 83% of pregnant women nationally (5); however, other estimates from the UN suggest that the national rate may be closer to 76% (12). In the eastern regions, Mullany and colleagues found that, prior to any intervention on their part, antenatal care in that area covered less than 40% of pregnant women (13). Even with antenatal care coverage, many mothers still suffer from poor nutrition, anaemia, or malaria. A significant lack of skilled birth attendants has been noted; one midwife is often responsible for five to 16 villages (15).
The Ministry of Health, quoting data from 2008, suggested that 76% of pregnant women received skilled attendance (11). Other non-governmental bodies suggested that it may be closer to 57% (12,16). Grundy et al., quoting a 2011 WHO report, suggested that as many as 73% of Myanmar's women gave birth in village homes in the care of nonprofessionals (17). In contrast, skilled attendance in the eastern regions has been documented as low as 5% (13). Emergency obstetric care is inadequate nationally (5).
Accessing care is particularly difficult in the eastern provinces since the few available hospitals are at great distances from villages (18) and are dangerous to access due to landmines and ongoing conflict between the military and ethnic militias, seeking greater autonomy or independence for their regions. Ethnicity further places women at risk since the Myanmar Government consistently appears to provide fewer services to ethnic minorities. Healthcare is more deficient in regions of ethnic minority groups (19), and infrastructure is particularly poor in the rural areas of these regions (20).
Myanmar has struggled under military rule for more than 50 years. The military consumes 40% of the national budget while merely 2.2% is allo-cated to healthcare (5). The long-standing military government in Myanmar was also well-known for human rights abuses revolving around ongoing conflict with ethnic minorities (13). Research by the BPHWT has linked poor health indicators to the human rights abuses experienced in the eastern provinces (4,8). It is in this context that recent political liberalization in Myanmar has been encouraging. In March 2011, a nominal civilian government, headed by President Thein Sein, was elected, representing Myanmar's first non-military rule since 1962. The new government has sought to demonstrate leniency, recently releasing over 2100 political detainees (21). Among those released from house arrest was Aung San Suu Kyi, an internationally-renowned democratic figurehead. Finally, in recent years, the Myanmar Government has signed ceasefire treaties with several ethnic rebel groups (22).
The principal aim of this paper is to carry out an integrative review of the literature on the current status of maternal mortality in eastern Myanmar in the context of armed conflict between various separatist groups and the military regime. In the process, underlying factors contributing to maternal mortality in eastern Myanmar are examined. The authors discuss possible opportunities that liberalization may make available to the Myanmar Government, the international community, and non-governmental organizations (NGOs) in the fight to reduce maternal mortality.

Literature search
This integrative review of literature sought qualitative, quantitative and unpublished studies, and grey literature (grey literature refers to documents of the Ministry of Health, organizational reports, country documents, book chapters, and newspaper articles). An exhaustive electronic search, in English, through scholarly databases (Medline and Embase) and full-text journal databases (Proquest, Ovid and Science Direct) was conducted using the following key words: Burma, Myanmar, childbirth, civil war, death, development agencies, international aid, government, liberalization, maternal deaths, maternal health, maternal mortality, MMR, political unrest, policy, and pregnancy. The corresponding authors of publications in the field of maternal mortality in Myanmar were contacted via a standardized email for any outstanding unpublished articles. Of those authors who responded, only one had authored additional material on the subject. Grey literature was examined with Google and Google Scholar search engines, using the same search terms mentioned above. Unpublished documents were sought in electronic theses libraries. Hand-searching of relevant journals was also completed for the period spanning the six months prior to 31 July 2012 to ensure that any recent publications not yet available in databases were not overlooked. No relevant documents were found. All publications that entered the second phase of screening (see below) were examined for relevant titles from their references lists.

Screening of the studies
Documents selected for the review included published journal articles (n=8) and grey literature (n=10) published in English from 1 January 2004 to 31 July 2012. English was found to be the main language of these studies done in this area, and limited translation resources did not allow us to include any non-English publications. The dates chosen reflected the eight years prior to the study in order to reflect a recent picture of the maternal health situation in Myanmar (very few studies exist to further limit the time span and still retain a variety of information sources). Studies on refugees on the Thai-Myanmar border areas were excluded in order to prevent differing service levels between regions that would affect the results. An initial screening was carried out by examining titles and abstracts for relevance. Searching by key words occasionally generated papers with entirely unrelated and different contents, and these were excluded from the review. A second-stage screening was completed on full-length publications which met the above criteria. Document selection was conducted by the primary author in consultation with the tertiary author.

Data extraction
Data from qualitative and quantitative studies and grey literature were extracted thematically via a line-by-line coding process (23) and entered in a spreadsheet (Table 1). Study designs and outcomes from quantitative studies were also extracted.

Data analysis
Qualitative data were coded line-by-line, and then categorized into descriptive themes (23). The themes were then regrouped into four further analytical themes based on principal aim and objectives of this study-a process based on the work of Thomas and Harden (24). These four themes were underlying factors of MMR in the eastern regions 1a is not missing, it is the first item in the 'MHC Services' section of the table. The items are not in sequence because, when these were grouped into broader themes (as described in the methods section), these maintained their numbering and lettering

Contd.
relating to: the health system, conflict, politics, and socioeconomics. The quantitative data were coded into the descriptive themes described above and translated into the analytical themes to seek sources of convergence (25). Quantitative data were presented in a narrative style as well as numerically, to address the objective of each study. Statistical metaanalysis was beyond the scope of this study, and there were only a few quantitative studies to meet the requirements for such an analysis. Findings from the quantitative studies helped complement the themes emerging from the qualitative studies.

Data synthesis
Analytical themes were generated based upon the combined qualitative and quantitative findings to synthesize the findings into an overarching framework (23). Some themes were deductively created (e.g. political factors) where the authors postulated broader themes likely to be present in the literature while others evolved through an inductive process where specific findings in the literature were generalized into a broader theme (e.g. socioeconomic factors).    Trust necessary for timely care to be achieved Some EOC services can be delivered in the community Challenges to MHC service delivery were overcome (e.g. security problems, transportation issues) Successes: impartial care and consistent support of communities in turmoil, increased MHW confidence, expansion of family planning services, increased collaboration between 3 tiers (Traditional birth attendant, health worker, maternal health worker), expansion of TBA roles in some communities (e.g. prophylactic misoprostol) Contd. Table 2 provides a summary of the quantitative (n=5) and qualitative studies (n=2) and review articles (n=1) found through a detailed literature search. Table 3 lists the 11 themes, which were synthesized from these studies (n=8) in combination with a qualitative summary study (n=1) and publications sourced via the grey literature search (n=10). Underlying factors that influenced high MMR in eastern Myanmar could be broadly categorized into the following themes:

Health system-related underlying factors for MMR in the eastern regions
Access to and availability of maternal healthcare (MHC) services was an underlying factor identified in the review. It appeared in 11 of the 19 publications studied. Grundy et al. found that, despite a maternal mortality rate higher than in other southeast Asian countries, per-capita aid-flows to Myanmar were among the lowest in the region (17). They described the health system as being on the verge of collapse in 2012. A report by the Hauser Center suggested that short-term donor funding prevented adequate healthcare service delivery by the participating NGOs in the study (26). For instance, 88% of women delivered their babies at home (13).
In a 2008 study, the authors stated that it was necessary to decentralize the provision of healthcare to properly serve the eastern regions of Myanmar where a community-based delivery system could allow many of the necessary pregnancy and delivery services to be provided (27). The three-tier health worker system used by certain NGOs in the area was designed whereby maternal health workers provided a wide range of MHC services, and health workers and traditional birth attendants (TBAs) provided a narrower range of services (27). This three-tier system has improved the accessibility of care for many women in the region (28). However, the overall lack of availability and of userfriendliness of MHC services was compounded by difficult access (transport, fees, etc.) (13,28).  (13). In a later study, Mullany and colleagues found that, after implementing a community-based MHC project, women were more likely to receive antenatal care (71.8% vs 39.2%), were twice as likely to receive postnatal care, and were 10 times more likely to have skilled attendance at birth (28). In a qualitative study based upon the same project (29), the authors found that some EOC services can be delivered in a community setting, particularly with increased collaboration between the three tiers of service providers and an expansion of the role of TBAs in certain regions.
Contraception was identified as an area of concern by four of the publications. Approximately 80% of women in two BPHWT studies had not used contraception (4,8). A study by Mullany et al. found that greater than 60% of women had an unmet need for contraception (13). In the eastern regions, older women reported an average of 6.9 pregnancies, with 88% of their most recent births occurring at home (13). Forced relocation was associated with 6.1 times decreased use of contraception (8).
The MOM project implemented community-based MHC, which resulted in a decrease in unmet contraceptive need from 61.7% to 40.5% of the women surveyed, and an increased use in modern contraception from 23.9% to 45% (28).

Underlying political factors of MMR in the eastern regions
Government-imposed limitations on NGOs working in Myanmar and the hindrances the organizations face were underlined as areas of concern in 11 of the 19 reviewed publications. The Hauser Center's publication identified a number of findings, including a lack of expatriate staff mobility, fluctuating visa approvals, and governmentimposed travel restrictions (26). These findings are compounded by limited NGOs' access to regions of ethnic minority groups within Myanmar and serious ethical and operational dilemmas. Identified ethical dilemmas included how to provide appropriate assistance in a humanitarian environment that is tightly controlled by the Government and the military. The creation of parallel structures (through aid-delivery by multiple sources) was found to be another significant operational dilemma facing NGOs in Myanmar (26) according to a report by Saha (2011).
A lack of health-related data in Myanmar and in the eastern regions in particular (including maternal health data) was identified as an underlying politically-driven factor by 5 of the 19 publications. For instance, NGOs have difficulty in gathering data on the impact of their services due to the restricted mobility of their expatriate staff (26). Myanmar's Ministry of Health regularly underestimates national health indicator data (8), and these data are generalized for the eastern regions where, in fact, minimal data are collected. Therefore, the unique health needs in the eastern regions are neglected.

Underlying socioeconomic factors of MMR in the eastern regions
Co-existing morbidity among pregnant women in eastern Myanmar was identified as an underlying factor in 5 of 19 publications. In the BPHWT study, 7.3% the of the household heads were found to be positive for falciparum malaria (4), a figure closely mirrored by another study which found a rate of 7.2% in the women surveyed (13). Bednets were present in 21.6% of households (13). Malaria was the largest cause of death in another study (8).
Eighteen percent of all those surveyed in BPHWT's 2010 study were malnourished (4) while another study noted that many of those surveyed were malnourished with an average mid-upper armcircumference of 24.4 cm among adult females (13). The same study (13) found that over 50% of women surveyed were anaemic with haemoglobin counts of less than 11 g/dL in greater than 60%.
Only 11.8% of women had received iron supplements during their previous pregnancy (13) while, in another study, only 14.7% of women met international recommendations for iron supplementation (4). An earlier study found that 40% had received iron supplementation (8). The same BPHWT study found that greater than 60% rarely or never used a latrine, and greater than 30% rarely or never boiled their water (8). Diarrhoea was a common finding in the studies, with rates of 6.4% in the two weeks prior to the survey (4) and 9.8% in the households surveyed by the BPHWT (8).
Abortion was not reported or documented as a factor of importance to MMR in any of the publications reviewed. The studies indicate that the factors that appear to contribute to the higher maternal mortality observed in eastern Myanmar are strongly interconnected.

Interrelationship of underlying factors influencing MMR
The many inter-relationships among the underlying factors which contribute to maternal mortality in Myanmar's eastern regions are posited in the figure. The model in the figure was created to illustrate the complex inter-relationships of the themes that emerged from the review. The number of interrelationships is complex, and the authors discuss a selected few in the next section.

Health system-related underlying factors for MMR in the eastern regions
Access to and availability of MHC services present serious challenges to pregnant women due, in part, to their lack of availability from both Government and NGOs. Travelling to access services increased the likelihood of exposure to soldiers, which risks violence upon their persons, or exposure to landmines. Targeted health workers are also presumably less likely to risk confronting the military in order to ensure the availability of MHC services.

Conflict-related underlying factors of MMR in the eastern regions
The alarmingly high rates of exposure to HRVs, such as personal violation or violence which includes sexual violence can have a direct impact on the health of pregnant women. For instance, violence perpetrated by soldiers may place a pregnancy in jeopardy. Women who conceive as a result of these encounters may be less likely to access formal maternal healthcare (MHC) services as was the case in Rwanda (31). Even those who did not conceive might still be less likely to access MHC services when they did conceive, due to shame ensuing from their victimization, as suggested in research on victims of rape in northern Uganda (32). Furthermore, anecdotal evidence from Sierra Leone suggested that pregnancies secondary to conflict-related sexual violence may increase abortion-seeking, including unsafe abortions (33).
The removal of food as well as the means to purchase food may directly impact the health of pregnant women in eastern Myanmar since one study found it to be linked with an increased risk of death (30). Furthermore, women foraging for food in the jungle are more likely to come into contact with malaria-carrying mosquitoes (30), soldiers, or landmines. Women injured by soldiers were also less likely to be able to contribute to the raising of crops, which might impact on food security.
Forced labour prevented households from growing their own food or working in a remunerated capacity. Pregnant women forced into such labour were also more likely to be exposed to sexual or physical violence due to their close proximity to soldiers. Forced labour conditions were often unsanitary and unfamiliar, further exposing people to landmines, malaria (30), and other diseases. These conditions also reduced their access to appropriate food sources.
Forced relocation and displacement had a serious impact on food security and nutritional status of pregnant women since households were relocated away from fields and food storage facilities. It also increased women's risk of contracting malaria (e.g. not sleeping under a bednet), a condition which claimed the lives of many displaced pregnant women during the Afghan conflict (34). The odds of exposure to landmines were also increased with forced displacement (8) since women travelled in dangerous areas and foraged foods in unfamiliar territory.

Underlying political factors of MMR in the eastern regions
The lack of health-related data, particularly in the area of maternal health, from the eastern regions of Myanmar, is closely related to the difficulty that NGOs have in accessing this region. A lack of data on the severity of health concerns affected programme planning (26) and, in turn, the availability of the funding of NGOs. Ongoing conflict made it difficult to conduct research (35) due, in part, to the dangers associated with data collection in the region. A lack of appropriate data also posed challenges for the Myanmar Government and other service-delivery agents to making appropriate decisions regarding which MHC services were most needed. Limited data impacted on planning (26) which contributed to the poorly-tailored and geographically-disparate MHC service provision.

Emerging political changes
Myanmar has made encouraging changes recently; by-elections won by Aung San Suu Kyi's National League for Democracy and changes to the constitution and political structures suggest a liberalization and democratization of the country. The Government has also softened its attitude towards NGOs by giving them greater access to certain regions within the country (26). Additionally, the Human Rights Commission has been formed, and a number of military members have recently been sentenced for raping and murdering a woman of an ethnic minority group (26,36,37). Finally, a recent drive to produce a national ceasefire with the majority of Myanmar's ethnic armed groups is underway (38). These events all point to the possibility of substantial and real change in Myanmar. However, much remains that is troubling. Human rights violations continue (39)

Limitations of the review
The present review was conducted using the available publications that remain limited despite a wide-ranging literature search using a thorough, methodical and replicable process. Publication bias, typical of such reviews (43), was countered through the collection of unpublished documents, such as dissertations and grey literature. The quality of data may also be suspected, based on the data variability from source to source, i.e. Ministry of Health (8).
A subset of the publications included in the study focused on the reporting of HRVs in eastern Myanmar where maternal health concerns were a secondary focus or were not directly addressed.
Although the methodological rigour of the studies examined were practical for the conflict-prone areas under consideration, this did not allow us to determine the relative weights of the actual causes of increased maternal mortality in eastern Myanmar. A similar cohort of women receiving services from either the BPHWT or the MOM group (those who conducted the studies in question) could be included in a subsequent study to improve the strength of the results found. It is difficult to make a one-to-one link between some of the conflictrelated factors and maternal death from these studies. Nevertheless, these factors can all contribute to an environment that is detrimental to the healthy progress of pregnancy or maternal survival.

Conclusions
Further progress in Myanmar is essential to reduce maternal mortality in the eastern regions. To reduce the conflict-related underlying causes, measures must be taken to reduce the human rights violations occurring in the eastern regions. The Myanmar Government must develop a comprehensive plan that truly engages the ethnic minority groups in serious dialogue (22), one that can lead to national reconciliation. A call has been put forth by Suu Kyi and other political figures for holding a second Panglong Conference to bring ethnic leaders, together with the Government (39). This could be an important first step.
Furthermore, the Myanmar Government should enact laws which enshrine the rights of pregnant women. Without changing the prevalence of these conflict-related underlying causes (found in the study to be of greatest concern to women's health), the authors suggest that few other measures will have the lasting effect needed to reduce MMR in the eastern regions of Myanmar.
The conflict-related barriers to accessing MHC services are ongoing but can be mitigated. The provision of the government-funded mobile maternal health services, as suggested by Teela et al. (29), to the eastern regions, would greatly reduce these barriers. An alternative might be the creation of numerous health "safe zones" where ethnic women could access MHC services free from harassment or molestation by the military. This approach should be complemented by further funding and support from the international community for the existing exemplary cross-border initiatives that currently provide MHC services to this population.
Health system-related underlying factors contributing to high maternal mortality in Myanmar's eastern regions must also be addressed: a greater focus on maternal health provision to the communities in eastern Myanmar is crucial to reducing the unnecessary deaths (13,27). Another essential element of MHC that must be expanded is the provision of family planning services, or, "birth spacing services" in the terms of the Ministry of Health. Contraceptive services could be provided by government-employed community health workers who travel to the villages in which the minority women live. Finally, the underlying socioeconomic factors must not be ignored. Aid and humanitarian agencies must partner with the Myanmar Government, increasing aid-flows desperately needed to combat high maternal mortality in the eastern regions (17).